Most postgraduate schools in allergy and clinical immunology train residents in only one branch of the discipline: allergy and immunodeficiency, or clinical immunology. That's the assessment of Professor Lorenzo Dagna, who directs the school at Vita-Salute San Raffaele University (UniSR). There, allergy, clinical immunology and immunodeficiency are woven into a single, structured training path.
In a specialty that is among the broadest in medicine, Dagna describes this integration as the school's defining trait. «The diseases we treat are systemic, and they can affect any organ», he explains. Cardiology, gastroenterology, dermatology, ophthalmology, nephrology, haematology, pulmonology, ENT: anyone training in allergy and clinical immunology needs a working knowledge of all of these disciplines. For allergists and immunologists, multidisciplinarity isn't a matter of organisation; it's the basic condition of daily clinical work. The unit holds regular joint meetings with the departments it works with most closely, among them pulmonology, haematology and ENT, and residents take part as a matter of routine.
For the 2024-2025 academic year, Italy's Ministry of University and Research funded 86 training positions nationwide in allergy and clinical immunology. In Italy, this training runs through what's known as a scuola di specializzazione, the postgraduate equivalent of a residency programme. With so few funded positions nationwide, choosing the right training site matters more than it would in a less competitive specialty. A school that covers all three fields from year one, as UniSR's does, lets residents reach year four with a complete, structured profile and a clear sense of where to focus next.
The first year is a shared core curriculum. Residents rotate through the departments most relevant to the discipline, including internal medicine, haematology, infectious diseases, pulmonology and dermatology, building a broad clinical foundation before specialisation proper begins.
By the second year, the focus shifts to allergy and immunodeficiency, with a rotation at Policlinico San Donato, part of the San Donato Group and one of the international reference centres for hereditary angioedema. The entire third year is devoted to systemic inflammatory diseases, both rheumatological and autoimmune. In the fourth year, residents go deeper into whatever interests them most, often through a period abroad. As Dagna puts it, the programme has no “watertight compartments”: a fourth year focused on allergy can still include work in other areas, though weighted towards the resident's own interest.
UniSR currently admits three residents a year, a number deliberately kept below the school's actual training capacity. That choice gives each resident exposure to clinical and research cases well beyond the legal minimum.
The immunology unit at San Raffaele Hospital treats some of the most complex rare immune-mediated diseases. IgG4-related disease, an inflammatory condition that can affect multiple organs at once and form tumour-like masses, is among the topics residents find most compelling. Just as relevant to their training: Erdheim-Chester disease, a rare form of systemic histiocytosis, eosinophilic granulomatosis with polyangiitis (EGPA), and primary hypereosinophilic syndrome, along with specific forms of immunodeficiency treated jointly with paediatrics.
Seeing these cases during training isn't only a research opportunity; it's what makes it possible to recognise them years later. A rare disease rarely presents with unambiguous symptoms, and the first obstacle to diagnosis is often just recognising that the condition isn't a common one. A study published in Orphanet Journal of Rare Diseases, looking at patients with rare diseases including primary immunodeficiencies and myositis, found that a physician's prior clinical experience with a specific condition is often what allows them to recognise it. A case seen once remains a point of reference for years.
The same unit is also a reference point for complications from cancer immunotherapy, working with the Cancer Center at San Raffaele Hospital, Milan's IEO (European Institute of Oncology), and the Istituto Nazionale dei Tumori. The most complex cases of immune-mediated reactions to checkpoint inhibitor drugs land here.
A systematic review of 50 clinical trials, published in Frontiers in Immunology, puts the median rate of severe (grade 3/4) immune-mediated adverse events at around 21% among patients treated with these drugs. That figure explains why managing these complications takes dedicated specialist expertise.
Every resident in UniSR's allergy and clinical immunology school completes a period of training abroad, or at least outside the institute, at a site chosen to match their own interests rather than a fixed track. In recent years, residents have spent time at Massachusetts General Hospital in Boston to study IgG4-related disease, in Paris, Marseille and Barcelona for myositis and systemic disease, and in Padua, home to one of the world's reference centres for paediatric food allergy.
«First and foremost, specialising in immunology and allergy takes solid foundations and a real passion for internal medicine», Dagna says. The second requirement, he adds, is breadth of perspective: «As I said, you need competence across different internal medicine specialties: cardiology, gastroenterology, dermatology, ophthalmology. Multidisciplinarity is crucial». Finally, residents need to stay open to continuous learning and change. «It takes a genuine appetite for innovation», Dagna says, «because most of the treatments in use today didn't exist twenty years ago».
There's also a less predictable side to the job. «Ninety-five per cent of the diseases we treat as immunologists have no explanation. We don't know why they arise. Looking for the cause, more than just managing it clinically, remains one of the main drivers of our work», he observes.
«You have to be honest about how vast and complex our discipline is. To me, it's far more honourable to have doubts, and to go back to studying and researching, than to speak without having done the reading. I suggest that younger colleagues treat moments of uncertainty as a chance to return to a book or an updated resource. And I always encourage them to take an active part in national and international conferences. Watching them present their own data at a conference is another achievement that gives me real satisfaction», the director concludes.
It's a portrait that explains why, for anyone weighing a specialisation in allergy and clinical immunology, the decisive factor isn't just the number of funded positions on offer, but the structure of the training itself. At UniSR, allergy, clinical immunology and immunodeficiency stay interwoven from the first year to the last.